On Election Day, Lu Anne Dinglasan and Alex Diaz de Villalvilla joined in their fellow medical students gathering near the lobby of Yale New Haven Hospital. About 20 students dressed in short white coats paired off with mentors like Dr. Auguste Fortin to practice interviewing patients.
Fortin, whose thin, braided ponytail hangs midway down the back of his long white coat, greets Dinglasan and Villalvilla with a hug. He directs them to the elevator, which they ride to the ninth floor to meet the patients who have agreed to be part of their learning process.
Fortin's second-year Yale University medical school students are learning how to ask about their patients' spiritual lives as part of understanding the bigger picture of what brings people to the hospital.
"You're going to be asking some pretty personal questions in a minute, and what gives you the permission to do that is to connect with the patient on their terms," Fortin says quietly as health-care professionals whisk past the corner where he's giving the students a pep talk.
Villalvilla, 25, holds a packet of pages that outline important areas to cover when asking patients about their histories: from the impersonal, such as occupational exposure to chemicals and seat-belt use, to the emotional, such as spirituality and sexuality.
Though sexuality may not be the easiest thing to talk about, Fortin says, "I usually start with: `Who's at home with you?'
"If you say it in the same way as, `What do you do for work? Tell me about your schooling,' your sense of professional, respectful curiosity then translates into their willingness to take the question. If we do too much coughing and stammering and our voice trails off, the patient gets the idea that this is something embarrassing or shameful."
Dinglasan, 23, who has never asked real patients about their social background issues, looks up from her papers and asks, "Is there any certain order to these things?"
"My suggestion would be not to start with sexuality, not to start with spirituality, not to start with illicit drugs."
Spirituality, for some people, is as sensitive a topic as sexuality, domestic violence and alcoholism. And it may be as important for doctors to find out about.
Fortin says that despite their sensitivity, patients want health-care providers to ask about these issues, but knowing how and what is appropriate to ask is a skill that needs to be taught in the medical school curriculum.
Back to the books
Getting at the reason a person comes to the hospital is the primary objective of any health-care professional. But pinpointing a disease or a physical ailment shouldn't be the only thing a doctor looks for, according to Dr. Robert Smith.
Smith, a professor of medicine and psychiatry at Michigan State University, developed the interview method that Fortin teaches his students: the Integrated Patient-Centered, Doctor-Centered Interview. With a 1990 grant from the Fetzer Institute, Smith began the project to uncover patients' psychosocial needs that aren't typically addressed.
On average, doctors interrupt patients after only 18 seconds of speaking with them, Smith said. This "doctor-centered" interview, said Smith, "means that the patient doesn't get their first thought out of their mouths."
In Smith's model, the physician begins with a "patient-centered" approach. Developing that relationship between doctor and patient is what Smith calls "the essence of medicine."
This interview model allows patients to list the issues they want to discuss. Often, patients will bring up something that a physician might not think to ask about, including spirituality.
"I might tell you that I have headaches and that my grandfather died of a brain tumor," said Smith, as an example, "Then I might say, `I wish I hadn't quit going to church.'"
This admission, Smith said, gives doctors insight into a host of other psychological and spiritual factors that could influence patients' decisions to come to the hospital. "The ideal description of any patient is derived from that bio-psychosocial perspective," said Smith.
"For many people, it's the scientific appeal that convinces them," Smith said. "From a scientific standpoint, it's superior because it gives more patients satisfaction and increases patient compliance. There's less doctor-shopping. There are fewer lawsuits. The biggest one of all is that there are better health outcomes."
At the bedside
Fortin and Villalvilla scavenge the hallway for extra chairs. "If you hear me clearing my throat like I've inhaled a huge piece of dust," Fortin says to Villalvilla before heading into the patient's room, "that's probably a signal that we need to wrap this up if the patient is too loquacious."
Fortin introduces the patient, Mr. Abrahamson (whose name has been changed for issues of privacy), to Villalvilla, who draws a chair close to the bedside. Fortin and Dinglasan recede into the background to be "flies on the wall," Fortin tells Abrahamson.
Villalvilla begins the conversation by asking, "What has brought you into the hospital today?" He quickly learns that Abrahamson was admitted because of stomach pain caused by diverticulosis, and that he will be leaving the hospital tomorrow.
"And how old are you?" Villalvilla continues, in his pronounced London accent.
"I'm 74," Abrahamson replies. Villalvilla then asks about his employment, learning that Abrahamson is a retired engineer who has lived with his wife since they were married in 1957.
"And how is your marriage?" asks Villalvilla, using an open-ended question to elicit details about Abrahamson's home life and sexuality. Abrahamson declares that being married for over 40 years takes patience, understanding, "and when you have a mother-in-law who's living with you who doesn't keep her nose out of your business, it can be a living hell."
Though Abrahamson's mother-in-law has been dead for over 10 years, he still speaks about her with rancor. "I smashed her in the face," he volunteers. "I didn't feel very good about it, but I'll be damned if I was going to let her take over my house.
"That calmed her down. You'd be surprised how a mother can be very detrimental to her children."
Villalvilla, who sports a domestic violence awareness button on his lapel, registers surprise in his eyes, but maintains his tone of voice. Abrahamson continues the story of his mother-in-law, ending with, "The happiest day in my marriage life was when she died."
Villalvilla moves the conversation to issues of smoking, drinking habits, sexuality and spirituality. Though Abrahamson expounds at length on his personal theology - "God is a special kind of phantom" - he doesn't seem to understand Villalvilla's questions about incorporating spirituality into his health care.
"For example," Villalvilla says, "some people would like their food prepared a certain way, or they would like to see a pastor. Do you have such needs?"
"Do I need to see a pastor?" Abrahamson laughs, indicating that for him, a pastor is only necessary for last rites. "No, I don't need a pastor."
Down the hall, in an empty conference room, Fortin debriefs his students, still a bit shell-shocked from Abrahamson's disclosure of his home life: "What people will tell us when we have our white coat on!" says Fortin.
The real benefit of hearing any story like that, Fortin says, is the strength it adds to the doctor-patient relationship.
"It's like that [Henri] Nouwen quote, right? We're entering into the pain of the stranger," says Fortin.
"I think when there's an emotion in the room or right around the corner, it's OK to go there and usually it's the place go. It's developing our own comfort with that because instead of then fixing it, you're sitting with the pain."
Fortin and Villalvilla discuss techniques to elicit empathy: echoing a patient's words, sitting forward in one's chair and maintaining eye contact. "Empathy is another arrow in your quiver," Fortin says.
"So how did that feel, Alex?" asks Fortin.
"It felt really good, actually," Villalvilla says. "I was nervous at points. Especially at the end when he mentioned that his sex life was then something of a sore point. I really wanted some sort of breakaway question that was going to be uplifting."
Dinglasan admits that she feels especially uncomfortable asking patients about their sexuality.
"This is OK for you to talk about as a doctor," Fortin reminds her. "Not only is it OK, 91 percent of patients want their doctors to ask them about this stuff. And if you don't do it, you're not serving those patients."
Something I ask all my patients
Mr. Togrides (also not his real name) is lying back in bed, watching the initial returns of the November election, when Fortin comes in to introduce Dinglasan and Villalvilla. An argument over a respirator and intermittent beeping betrays the presence of another patient just behind the curtain that divides the room for privacy.
Dinglasan asks Togrides if she can make him more comfortable to talk as he fumbles to adjust his hearing aid. After Togrides is settled, Dinglasan sits forward in her chair and introduces herself.
Dinglasan gets a rambling introduction to Togrides' family history: his father came from Iran and his mother from Turkmenistan. His lineage was a factor, Togrides said, that actually helped doctors pinpoint an ethnic blood disorder uncovered after he came to the hospital having collapsed from pneumonia.
Dinglasan waits patiently for a break in the conversation.
"I am wandering? When I get like this, I'll talk about anything under the sun, including the elections today, God help us!" says Togrides, adding that being 80 makes him prone to talking at length.
Togrides has been in the hospital almost a month; Dinglasan asks if people have come to visit him. He answers that his family, most of whom are local to the New Haven area, visit him regularly, including his "girl."
Like Villalvilla, Dinglasan uses the open-ended question, "And who's at home with you?" to better understand his living situation. Togrides says that he's been living alone since the day his wife died. Coincidentally, it's the same day that, 79 years ago, his current partner was born. "You don't think that's providence?" he says.
Dinglasan is quick to turn this admission into a question about his spirituality. "It sounds like that's an important part of your life: providence and spirituality," she says.
"Does your spirituality and your involvement with the church influence the way that you take care of yourself?" Dinglasan asks.
"No, it's not that kind of religion," says Togrides. "It's an inner thing. An inner peace."
Though it's clear that Togrides doesn't connect spirituality to his health care, he admits that members of his church and his priest are important to his emotional well-being. "Does it help you cope then?" Dinglasan asks.
"I don't know. It's getting to that point, I think," Togrides muses.
Dinglasan steers the conversation through drinking, smoking and chemical exposure, and then comes back to the subject of Togrides' partner, the girl of providence.
"She was a bit more forward than me, but that was fine," Togrides says.
And with only a moment's hesitation, Dinglasan asks, "Are you intimate with her?"
"Yeah! My wife was sick with diabetes; I couldn't touch her for 20 years," Togrides says. "I'd touch her and she would hurt. We'd be in the car and I'd put my hand on her, she'd pull away. She hurt all over. So, I'm making up for lost time."
"Do you have any trouble being intimate with her?" Dinglasan asks.
"No!" he says proudly. "I don't have any more problems than an 80-year-old person."
It's all in the asking
A recent study out of the University of Ohio showed that 91 percent of patients report their doctors have never asked about spirituality, and that most patients want to be asked. However, because most patients are not usually asked, said Fortin, the importance lies in the way of asking the question.
"I've never seen a person become offended by it," he said, because the patient-centered interview begins in an "open and nonjudgmental way."
Taking a spiritual history might begin by asking the patient: Do you consider yourself to be a spiritual or religious kind of person at all?
"If the patient says, `Oh God, forget about that - no way!'" Fortin said, "you say, `OK, next question: Do you wear a seat belt?'"
However, if patients get uncomfortable with the subject of spirituality being raised in a medical setting, Fortin has a simple answer: "Religion and spirituality are important to some of my patients, especially when they get sick, so I like to know, for all of my patients, whether it's important or not."
Fortin added: "I've said that many times to patients who kind of cocked an eyebrow when I ask the question, and they go `Oh, OK.' And then I say, `And now I'm gonna ask you some more questions I ask all my patients: Do you have smoke detectors in your house? Do you have any guns in your home? Do you wear seat belts?' Other questions that are important for keeping people healthy."
At the other end of the scale, asking about spirituality and religion may garner the opposite reaction, with patients asking their doctors to pray with, or for them. Fortin said that the curriculum addresses this issue head-on.
"Just as if the patient had a nutritional problem, we would probably consult a nutritionist rather than try to handle it ourselves. With the patient, if we identify a spiritual problem, we refer the patient to the chaplain," he said.
Dr. Katherine Gergen-Barnett, who worked with Fortin to develop the curriculum, agreed that it's important for students to learn the boundaries between doctor and chaplain so that they can make appropriate referrals. "We can often serve as the catalyst for a person getting the support they need spiritually from the right person," she said.
Though Fortin admitted he doesn't pray with patients, he said he believes doctors can if that feels appropriate. But more importantly, doctors still need to recognize that they might not be the right people for the job. "I've called pastors for patients when I've communicated bad news so that they could come up and pay a visit, or consult a hospital's chaplain to be able to provide some spiritual support," he said. "I don't feel particularly trained to do that."
The votes are counted
After leaving Togrides to watch the continuing election coverage, Fortin, Dinglasan and Villalvilla convene in a doctor's lounge. "I smiled, you couldn't see, but I thought your choice of words in that regard was perfect," said Fortin, praising Dinglasan's ability to ask about an uncomfortable subject.
"It's so helpful for those of us on this side of 80 to realize that it's OK, and people do have sex at 80 and it's never not appropriate, based on age, to ask the question. I think a lot of doctors would have thought this guy's sex life was over ages ago. Baloney," Fortin said.
"I want you to know how proud I am that you talked to him about sex. I know that was the biggie for you. And you got there and you got there in a professional, caring way.
"You got an answer that if you were this guy's doctor, that's important data. And are you going to do something with that data? No, but now I know there's nothing I need to do."
Villalvilla smiles at Dinglasan, "He wasn't taken aback."
Fortin concludes the session, "And why wasn't he taken aback? Because of the way you asked the question."